Laserfiche WebLink
.,....a .. ....... ...z. �...� .,,... <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnes�ota Well and Bonng �H 14 l 5 2 9 � <br /> ry WELL AND BORING SEALING RECORD Sealin No. <br /> Coun Name �Q Minneso:a Unique No. — <br /> `ennipen rD M�nnesota Statutes.Chapter 1031 or W-series No � <br /> ILeave Dlank il not known) <br /> Township Name Township No. Range No. Section No. Fracuon�sm.-s Ig.) Date Sealed Date Weli or Bonng ConsVucted <br /> 1 tE 23 36 4�-1��:�i � � <br /> Numerical Street Address or Fire Number and Ciry of Well or Bonng LocaGon ay / f � <br /> G t Ch��,�� (.��5@' ��1t7�� (lila�/2atd DepthBeforeSealmg � 1..�ft. OriginalDepth /�� R. <br /> Show exact location ot well or boring Sketch map of well or bormg AO IFER�S) STATIC WATER LEVEL <br /> in section� c, bcation. showing Yproperty Sin le A uiter <br /> �5�(�'� g q ❑ Multiaqwter <br /> 6nes,roads,and buildings. <br /> WELVBORING Measured ❑ Estlmated <br /> '�._.2-�: 'r, : _ � C . <br /> Water Supply Well ❑Monit.Well � <br /> � ❑ Env.Bore Hde ❑Other ��,�R. �below ❑above IarW surtace <br /> a�✓..)�L 1 <br /> W -�r- - - - — --i— E _ -- - -- CASING TYPE�S) <br /> --f- ---- -;-- ---1-- � Steel ❑Plastic ❑Tile �Other <br /> 1 'b mile � <br /> __�_ � CASING <br /> -i-- -�-- --i-- <br /> Oiameter Depth � Set in oversize hWe9 Annualar space inrtially grouted? <br /> S 1� �� <br /> ��,,,;�,�y fn.from v to � �� n. ❑ ves �No ❑ ves ❑No ❑Unkrawn <br /> I <br /> PfiOPERTY OWNER'S NAME in.trom to k. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> rU�@ B1ct11tL � 1�r .�. '— � <br /> Properly ownefs mailirg address if different than well locatlon address mdlcated above. in.trom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br /> ,�// '��' / <br /> � Screen from�to J��L ft. Open Hole from to R. <br /> OBS7RUCT10NS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill ❑ No Obstruction /� <br /> WeN owr�s meiling address if diMerent than property owner's adtlress indicated above. Type of Obstructqns(DOScribe) .-.L-1V��� !�� Q / U/�i� <br /> Obsirudions removed? Yes ❑ No Describe <br /> PUMP <br /> TY� ��� ��m� <br /> OEOLOOICA�YATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Ofher <br /> FORMATION <br /> M nd known,irWicate estimated tortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINCaS,OR CASING AND BORE HOLE: � <br /> .,/ �No Annular Space Exits <br /> (..,�} .et... <br /> ❑ Annular space grouted with tremie pipe��, <br /> 4 ❑ Casing PeAwation/Removal <br /> in.hom to ft. ❑ Pertaated ❑ Rertaved <br /> in.from to it. ❑ PeAaated ❑ Removed <br /> Type of perforata <br /> ❑ other <br /> GROUTING MATERIAL(S) <br /> � r�/� � /��,y��,./�'�� i <br /> Groudng Material,�.sr-�._t'��lL""►r6m � to��ft. yards �_ begs <br /> from to It. yards b�s <br /> from to R. yards begs <br /> from to_— fl. yards begs <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIRCATION <br /> �� � � � This well w boring was sealed in ecoordence with Minnesota Rules,Chapter 4725. The i�fortnation oontained in Crs repat ia . <br /> true ro the best of my krawledge. � <br /> � - DGId S�'aDCLh �tELL DFLTLLSRIG CO. , 1N{:. ?.7 1/:� <br /> Contractw Business Name Licgnse or Reyrstratiorr lio. <br /> a ��f:�..;;\,.� � ! �` <br /> ._ � - -�;�''r`�� . , �/ � > . %;"J <br /> , fefrv9 Signe(ure 09M <br /> `� � _��..,s,.,�~ <br /> ��`a ,,,-.- �"�..J <br /> LOCAL COPY H 1�l 5 2 9 Name al Person Sealiny ,eM a Baing <br /> ME-01�31-03 <br />